XERESE® Access Activation Site

Welcome

This program is only available to residents of the United States (except where prohibited, taxed, or otherwise restricted) and US territories including Puerto Rico and the U.S. Virgin Islands. Commercially insured and eligible uninsured cash-paying patients, as well as certain cash paying patients are eligible; individuals who are eligible for reimbursement of prescriptions, in whole or in part, by any federal, state, or other governmental programs, including Medicaid, and Medicare are not eligible to participate in this program. If your insurance changes, you may no longer be eligible to use this coupon. The XERESE Savings Co-Pay Card can be processed exclusively at Walgreens and other participating independent pharmacies.

* Required fields.

Please enter the 10-digit GRP# from the card you received. *

GRP# is invalid.

Please enter the 11-digit ID# from the card you received. *

ID# is invalid.

Are prescriptions of the patient who will use this XERESE Savings Co-Pay Card paid in part or in full under any federal, state, or other governmental programs, including, but not limited to, Medicare (including Medicare Advantage and Part A, B, and D plans), Medicaid, TRICARE, Veterans Administration or Department of Defense health coverage, CHAMPUS, the Puerto Rico Government Health Insurance plan or any other federal or state healthcare programs? *

Yes

No

Does the patient who will use this XERESE Savings Co-Pay Card have commercial (in part or in whole) prescription coverage? *

Yes

No

By checking here I certify that the patient, or caregiver activating on behalf of the patient is 18 years or older and understand that any person that is 65 years of age or older without commercial insurance is not eligible to receive this offer. *

Patient Date of Birth *

You must be 18 years of age or older to redeem this offer for yourself or a minor. Please enter Date of Birth information in the following format: MM/DD/YYYY using only numeric characters.

Please confirm that, by activating this XERESE Savings Co-Pay Card, you have read, understand and will comply with the terms and conditions of the program and that the patient who will use this card currently meets all eligibility criteria. Please visit www.xerese.com to see the full eligibility criteria and terms and conditions for this program. *

Yes

No

By using this XERESE Savings Co-Pay Card, you are confirming that you understand that the personal information you provide and information pertaining to the use of this XERESE Savings Co-Pay Card at the pharmacy will be shared with OraPharma, and third parties working with (or for) OraPharma. *

Yes

No

I authorize OraPharma, and companies working with or for it, to communicate with me by email, about products, including marketing materials, health conditions, co-pay and financial assistance. I agree to be contacted at the email I provided. OraPharma and companies providing services to OraPharma will not sell or rent my personally identifiable information, as described in the Privacy Policy. *

Yes

No

You will get a copy of the copay card emailed to you.

Email address *

Please enter a valid email address.

By submitting your information you confirm you read and agree with the terms of the Privacy Policy.

Eligibility Criteria/Terms and Conditions:

By using the XERESE Savings Co-Pay Card, you confirm that you understand and agree to comply with the following terms and conditions of this offer:

• This offer is only valid for patients with commercial insurance and eligible uninsured cash-pay patients.

• This offer is not valid for any person eligible for reimbursement of prescriptions, in whole or in part, by any federal, state, or other governmental programs, including, but not limited to, Medicare (including Medicare Advantage and Part A, B, and D plans), Medicaid, TRICARE, Veterans Administration or Department of Defense health coverage, CHAMPUS, the Puerto Rico Government Health Insurance Plan, or any other federal or state health care programs.

• You agree not to seek reimbursement for all or any part of the benefit received through this offer and are responsible for making any required reports of your use of this offer to any insurer or other third party who pays any part of the prescription filled.

• This offer is good only in the United States of America (including the District of Columbia, Puerto Rico and the U.S. Virgin Islands) at retail pharmacies owned and operated by Walgreen Co. (or its affiliates) and other participating independent retail pharmacies.

• This offer is not valid for any person that is 65 years of age or older without commercial insurance. You must be 18 years of age or older to redeem this offer for yourself or a minor.

• You must present this XERESE Savings Co-Pay Card along with your prescription to participate in this program.

• This XERESE Savings Co-Pay Card is good for use only with the products identified herein. No other purchase is necessary.

• This offer cannot be redeemed at government-subsidized clinics.

• This XERESE Savings Co-Pay Card is good for a limited number of fills only. For a complete listing of the maximum number of fills for which this offer applies, please review the program terms and conditions, which are posted at www.xerese.com.

• Reimbursement limitations and maximum benefits apply. Patient is responsible for all additional costs and expenses after reimbursement limits are reached.

• This XERESE Savings Co-Pay Card and offer are not health insurance.

• The selling, purchasing, trading, or counterfeiting of this XERESE Savings Co-Pay Card is prohibited by law. Void if reproduced.

• This offer is not valid with other offers. This XERESE Savings Co-Pay Card has no cash value. No cash back.

• This offer expires on December 31, 2020.

• OraPharma affiliated entities reserves the right to rescind, revoke, terminate, or amend this offer at any time, without notice.

• You understand and agree to comply with the terms and conditions of this offer set forth above and at www.xerese.com